Paul Ryan’s claim that ‘more and more doctors just won’t take Medicaid’

“The problem that we’re seeing in Medicaid is more and more doctors just won’t take Medicaid, because they lose money on Medicaid.”— House Speaker Paul D. Ryan (R-Wis.), town hall on CNN, Jan. 12, 2017

During a town hall on Republican plans to repeal and replace the Affordable Care Act, Ryan described the need for changes to the Medicaid program at the state level. Some states made changes so that low-income enrollees could get coverage and access to care, but not all states did, he said.

Ryan claimed that “more and more doctors just won’t take Medicaid because they lose money on Medicaid.” He also said during the town hall that his concern was that Medicaid is “so over-regulated and so bureaucratic that physicians just won’t take Medicaid patients. And so our concern is that people on Medicaid can’t get a doctor, and if you can’t get a doctor, what good is your coverage?” We explored the facts.

The Facts

Low payment rates are often cited as the main reason doctors don’t want to participate in Medicaid. Doctors also cite high administrative burden and high rates of broken appointments. So Ryan is addressing a real problem that doctors face when participating in Medicaid.

But Medicaid is run by the states and their health-care provider networks, so there’s not a central system where doctors report whether they have stopped seeing Medicaid patients.

Ryan’s staff pointed us to studies showing the likelihood that physicians will no longer take Medicaid patients after a pay increase expired in 2015. Under the Affordable Care Act, primary-care doctors who see Medicaid patients received a temporary pay raise. This was intended to help doctors as states expanded Medicaid eligibility to more patients under the health-care law.

The pay raise, which was fully funded by the federal government, expired at the end of 2014. News reports and studies at the time of the expiration showed that the primary-care doctors will see fewer Medicaid patients because they won’t be getting paid as much as they did under the pay raise. Experts warned that the expiration of the fee bump would restrict access for Medicaid enrollees.

While some states decided to extend the fee bump, 23 states did not. The Urban Institute’s analysis found that in the states that did not extend the fee bump, primary-care fees would fall by an average of 47 percent.

“Because doctors have had the reimbursement for seeing Medicaid patients reduced so significantly, it stands to reason that they’d see fewer Medicaid patients,” Ryan spokeswoman AshLee Strong said.

But whether the expiration of the fee bump actually restricted patients’ access is unclear.

The Medicaid and CHIP Payment and Access Commission (MACPAC), a nonpartisan legislative branch research agency, conducted interviews in summer 2014 in eight states to study the impact of the primary-care fee bump. At the time, there was not enough evidence to conclude whether the payment increase had any impact on provider participation or access for Medicaid enrollees.

Officials interviewed for that study said the fee bump had little to no effect on physician participation rates. It didn’t help to recruit Medicaid primary-care providers, either. A 10-state study by MACPAC found that there was a modest increase in the number of Medicaid patients or appointments during the fee increase.

Moreover, some 18 states decided to extend the primary-care fee bump fully or partially beyond 2015. It’s not yet clear whether the states that extended fee bumps had better Medicaid patient access to care than other states, said Stephen Zuckerman, senior fellow and co-director of the Health Policy Center at the Urban Institute. But so far, the data does not support Ryan’s claim, he said.

“The evidence that more and more doctors are not taking Medicaid, I don’t think it’s being reflected in the data I’m seeing so far,” said Zuckerman, who is working on a study of the new data.

Zuckerman added that fee differences between Medicaid, Medicare and private insurances have existed for years, and the differences in fees aren’t growing in a dramatic way.

“Fees have been lower historically. … I don’t think physician participation is going down,” he said. Lower fees have “been a problem. There’s no question that physicians have been less willing to participate in Medicaid than other types of insurance. But from the patients’ perspective, they’re getting comparable levels of service.”

A total of 68.9 percent of physicians were accepting new Medicaid patients in 2013, compared with 84.7 percent for private insurance and 83.7 percent for Medicare, according to the National Center for Health Statistics. These rates have been stable since then, according to MACPAC.

“I am not aware of any data source that would tell you one way or another whether the number of physicians who accept Medicaid or Medicare, or private insurance for that matter, is going up or down,” said Julia Paradise, associate director of the Kaiser Family Foundation’s Program on Medicaid and the Uninsured.

Paradise said one way to glean that information is by measuring patients’ access to care: Are they able to get basic primary care? Do they have a usual source of care? Have they had a visit in the past year? Paradise warned against looking just at the sheer number of doctors or just the physician participation rates.

So how do Medicaid enrollees fare? There are mixed outcomes because state programs vary. But in general, children and adults enrolled in Medicaid are as likely to have a usual source of medical care as those with private insurance, according to a November 2016 MACPAC brief studying 2014 National Health Interview Survey data.

MACPAC’s study found adults with Medicaid were as likely to have a usual source of medical care as those with private coverage. Medicaid beneficiaries also were as likely to have seen a doctor in the past year as adults with private insurance. Compared with uninsured adults, Medicaid enrollees were considerably more likely to have seen a doctor in the past year.

But Medicaid enrollees do face more barriers — such as delays because of transportation problems and difficulty finding doctors who accept their insurance — compared with those with private coverage. Medicaid enrollees, on average, face more delays in getting appointments than those with private insurance. And Medicaid patients have more difficulty finding specialists who will treat them, compared with people with private insurance.

Polling shows that broadly, the public and Medicaid enrollees have a positive view of Medicaid and Medicaid expansion. In a 2015 Kaiser Family Foundation poll, 65 percent of people covered by Medicaid said the program is working well. It found 47 percent of the public wanted the federal government to keep Medicaid spending “about the same,” 37 percent wanting spending increased, and 13 percent wanting it decreased.

The Pinocchio Test

Ryan highlights a real problem of lower fees for doctors who take Medicaid patients, and the potential impact on patients’ access to care. But there’s not enough data so far to support his claim, especially in the insurance landscape after some states extended pay increases for doctors who take Medicaid patients.

Experts who study the data say they have not yet seen evidence that fewer doctors are taking Medicaid patients. One way they measure that is by looking at patients’ access to timely care. The level of access for patients varies across states, and there are mixed outcomes. Medicaid enrollees report facing more problems getting appointments than those with private insurance, and finding specialists. But in general, Medicaid enrollees are as likely to have a usual source of medical care as people with private insurance.

If new information emerges, we will update this fact-check. But there is not enough data available to support Ryan’s claim. We award him Two Pinocchios.

Michelle Ye Hee Lee is a reporter on The Washington Post's national political enterprise and accountability team, covering money and influence in politics. Previously, she was a reporter for The Post's Fact Checker and a government accountability reporter at the Arizona Republic.